Provider Demographics
NPI:1427174879
Name:MOAK, EDWARD ERVIN (IDC)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ERVIN
Last Name:MOAK
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GLENHAVEN SQ
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-8600
Mailing Address - Country:US
Mailing Address - Phone:518-326-5653
Mailing Address - Fax:
Practice Address - Street 1:1 WEST AVE STE 230
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-6050
Practice Address - Country:US
Practice Address - Phone:518-583-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman